Open Access Original

Article DOI: 10.7759/cureus.788

A Quantitative Study on Anonymity and

Professionalism within an Online Free
Open Access Medical Education Community
Daneilla Dimitri 1 , Andrea Gubert 2 , Amanda B. Miller 3 , Brent Thoma 4 , Teresa Chan 5

1. Family Medicine, McMaster University 2. Resident, McMaster University 3. Emergency Medicine ,

Regions Hospital 4. College of Medicine, University of Saskatchewan 5. Faculty of Health Sciences,
Division of Emergency Medicine, McMaster University

 Corresponding author: Daneilla Dimitri, daneilla.dimitri@medportal.ca

Disclosures can be found in Additional Information at the end of the article

Abstract
The increasing use of social media to share knowledge in medical education has led to concerns
about the professionalism of online medical learners and physicians. However, there is a lack of
research on the behavior of professionals within open online discussions. In 2013, the
Academic Life in Emergency Medicine website (ALiEM.com) launched a series of moderated
online case discussions that provided an opportunity to explore the relationship between
anonymity and professionalism.

Comments from 12 case discussions conducted over a one-year period were analyzed using
modified scales of anonymity and professionalism derived by Kilner and Hoadley. Descriptive
statistics and Spearman calculations were conducted for the professionalism score, anonymity
score, and level of participation. No correlation was found between professionalism and
anonymity scores (rho = -0.004, p = 0.97). However, the number of comments (rho = 0.35, p <
0.01) and number of cases contributed to (rho = 0.26, p < 0.05) correlated positively with clear
identification.

Our results differed from previous literature, the majority of which found anonymity associated
with unprofessionalism. We believe that this may be a result of the fostering of a professional
environment through the use of a website with a positive reputation, the modelling of
respectful behaviour by the moderators, the norms of the broader online community, and the
pre-specified objectives for each discussion.

Categories: Medical Education, Healthcare Technology

Keywords: anonymity, professionalism, social media, free open access medical education, online
Received 03/29/2016
Review began 04/15/2016 discussion
Review ended 09/11/2016
Published 09/18/2016
Introduction
© Copyright 2016
Dimitri et al. This is an open access Social media, defined as the creation and exchange of user-generated content via virtual
article distributed under the terms of networks and communities using internet applications, is increasingly being used to share
the Creative Commons Attribution knowledge in medical education [1]. The FOAM (‘Free Open-Access Medical Education’)
License CC-BY 3.0., which permits
movement has led to a rapid growth in the use of blogs and podcasts as a delivery mechanism
unrestricted use, distribution, and
reproduction in any medium,
for online medical education in emergency medicine [1-2]. Educators and learners have turned
provided the original author and to platforms, such as Twitter, to create online communities of practice [3-8].
source are credited.

How to cite this article

Dimitri D, Gubert A, Miller A B, et al. (September 18, 2016) A Quantitative Study on Anonymity and
Professionalism within an Online Free Open Access Medical Education Community. Cureus 8(9): e788.
DOI 10.7759/cureus.788
 With the rise of social media in medical education, concerns have been raised about the
professionalism of the learners using these platforms. The literature contains review papers on
social media, but these papers often focus on the negative effects of social media usage by
learners [9-16]. Of note, Byrnolf, et al. investigated the potential breaches of medical ethics
committed by physicians and medical students on Twitter and found that unprofessionalism
was more common among users writing under pseudonyms than recorded names [9]. Although
their study found a correlation between unprofessionalism and anonymity, its analysis failed to
distinguish between personal and professional personae and the results may have been skewed
by personal accounts that were not intended to be part of the professional sphere. There is a
lack of literature on professionalism in open, online discussions that are conducted in
professional environments.

Studies regarding professionalism and online behavior are inconsistent. One study found that
pseudonymity, defined as the use of aliases, can play a valuable role in online learning and
increase participation [17]. A commonly cited theory, ‘the online disinhibition effect’, has found
that increasing anonymity using an online persona can lead to disinhibition that is either
benign or toxic [14, 18-19]. Some people disclose personal information and demonstrate
unusual kindness and generosity while others are critical, rude, and threatening.

In 2013, the ALiEM.com launched a series of online cases that prompted a global discussion
(The Medical Education in Cases Series) [20]. Each month, a case is launched from the blog to
which users can reply and discuss in the comments section. The cases focus on topics, such as
ethics, education, and professionalism. These monthly discussions have led to the development
of a community of practice that includes core members (ALiEM team members who act as
moderators), active members (frequent commenters), and peripheral participants (infrequent
commenters, readers). Case discussions are held openly on the ALiEM.com website, and
interactions between participants who are using social media for medical education or faculty
development can be publicly observed.

This study was designed to determine if there is a relationship between anonymity and
professionalism within this online community of practice. We hypothesize a clear link between
professional posts and identifiable individuals, while unprofessional posts are suspected to be
generated by anonymous individuals. Additionally, this study should help us determine if a
relationship exists between anonymity and participation. We hypothesize an increased rate of
participation associated with anonymity.

Materials And Methods

Study population
The study population consisted of participants who contributed to the ALiEM Medical
Education in Cases (MEdIC) Series discussions on the Academic Life in Emergency Medicine
website between September 2013 and August 2014. This study was granted an exemption by the
Hamilton Integrated Research Ethics Board since the data was already open and freely available
online.

Scoring
Scales derived and tested within a military population by Kilner and Hoadley were modified and
used to assess anonymity and professionalism [21]. Anonymity was defined using a four-level
scale that quantified the degree to which a user could be identified based on the information
presented within their comment (Table 1).

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 Level of Example
Description
Anonymity Identifier

1 Anonymous Anonymous

Njoshi8, Hans,
2 Username only (can include first or last name)
RP

3 Username that indicates full name Danica K

Username is probably real full name and/or they have other clear identifiers, i.e. picture,
4 Allan McDougall
credentials

TABLE 1: Coding Rubric for Anonymity of Discussion Comments

Professionalism was defined using a four-level scale that quantified the tone and contribution
of the comment to the overall discussion (Table 2). The definitions for the levels of the
anonymity and professionalism scales were modified according to agreed-upon descriptions by
the three raters that fit the online medical education environment currently studied. The
criteria for the highest level of professionalism (“Very positive: include multiple positive
criteria”) was not well-defined in the original study, and as such, our team refined for our
purposes to specify the positive contributions.

Level of
Professionalism Description Example
of Comment

1 Very negative: demeans with vulgarity Get lost you dumbsh*t!1

2 Negative: critical of another, or cynical You’re as screwed up as the Healthcare system. 1

3 Positive: supportive of another Great comment! I agree with…

In an age of evidence-based medicine now, we are also noting

Very positive: include multiple positive
that our patients may want different things from us... What
4 criteria, including the contribution of new
Doctors 'want'/think (sort of older, 2004 newspaper article):
ideas, resources, and discussion points.
http://news.bbc.co.uk/2/hi/hea...

TABLE 2: Coding Rubric for Professionalism of Discussion Comments

1These comments were used as examples from Kilner and Hoadley’s study [21]. The fourth criteria (“Very positive: include
multiple positive criteria”) was not well defined in the original study and was refined for our purposes to specify the positive
contributions [21].

Each comment was independently rated by three raters. Prior to rating, a calibration exercise
was performed by the three raters. One case discussion was individually rated by the three
investigators who then compared results, allowing for modification of scales where necessary.

2016 Dimitri et al. Cureus 8(9): e788. DOI 10.7759/cureus.788 3 of 8

 Following calibration, all comments made by discussion participants, but not moderators, were
rated independently by all three raters.

Statistics
To determine the extent of agreement between raters, intraclass correlation coefficients (ICC)
were calculated for the results from each scale. Median scores for each comment were
subsequently determined. Spearman correlations were calculated between professionalism
scores, anonymity scores, and level of participation (as measured by the number of cases each
participant contributed to and the number of comments that they made).

Results
The demographics of the MEdIC Series discussion website can be seen in Table 3.

MEdIC Series Website Visitor Demographics Between September 2013 to August 2014

Number of views of the ALiEM.com website per year 1.2 million

Number of views per case within the first two weeks 1,000

Total number of participants across all cases 76

Median number of participants per case Median (IQR )

Median number of comments per participant 1 (IQR1 1-8)

Total number of moderators across all cases 4

Median number of cases moderators participated in 7.5 (IQR1 4.75-12)

TABLE 3: MEdIC Series Website Visitor Demographics Between September 2013 to

August 2014
1 Interquartile range - IQR

There were 338 comments made by 80 individuals, including moderators, on 12 cases between
September 2013 and August 2014. The four moderators, with an average professionalism score
of three out of four, functioned as hosts and seldom contributed actively to the discussion.
Therefore, they were analyzed as a separate group, distinct from the participants-at-large.

After initial calibration, the ICC for the three raters were moderate-to-high, 0.81 (p < 0.001) for
anonymity and 0.57 (p < 0.001) for professionalism. Subsequently, all cases from September
2013 to August 2014 were scored by the three raters and the median scores were used for the
subsequent correlation statistics.

For non-moderator participants, the median professionalism score was four (interquartile range
(IQR) 3-4) out of four and the median anonymity score was four (IQR 3-4) out of four for
participants. Table 2 shows the raw percentage number of the comment quality in each month.
There was no correlation between the participant’s median professionalism and anonymity
scores (rho = -0.004, p = 0.97).

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 On secondary analysis, we assessed the relationship between anonymity and professionalism
with the extent of participation. There was a moderate correlation between both participants’
identifiability (as indicated by a high score) and the number of comments they made (rho =
0.35, p <0.01) as well as the number of cases that they participated in (rho = 0.26, p < 0.05).
Those who were more identifiable commented more. Professionalism also correlated with the
number of cases participated in (rho = 0.27, p < 0.05) but not the number of comments that they
made (rho = 0.076, p = 0.52).

Discussion
The findings in our present study differ drastically from previous work done in both our field
and in other related cases of online discussions. We found no correlation between participants’
professionalism and anonymity scores (rho = -0.004, p = 0.97). These results conflict with
recent observational studies, which found negative effects of anonymity on professionalism
both within the health professions [9, 22] and beyond [21]. One study found unprofessional
content more commonly among medical students and physicians writing under pseudonyms
compared to users writing under recorded names (p = 0.02) [9]. Another study conducted in an
online community of practice for American soldiers found that eliminating the option to post
anonymously reduced the negative comments by 89% [21]. Research on pharmacist bloggers
found that unprofessional language was associated with users who blogged anonymously
compared with those whose identity was disclosed [22]. While the ALiEM MEdIC online
environment permitted users to post anonymously, the proportion of negative comments was
much lower than that observed in these studies. No explicit instructions (e.g., code of conduct)
or active restrictions were imposed on the participants with regards to the level of anonymity or
the quality of comments.

There is a potential explanation for why our findings differed so dramatically from those in the
literature. First, the preservation of a positive social reputation may be a more significant factor
than concern for adverse repercussions in shaping participants’ online behavior [21]. Most
participants in our study are linked to the FOAM community in some way and were likely to
interact outside of the forum created by the blog [1]. The possibility that unprofessional
comments in this forum could affect participants’ reputation in this online community as a
whole may have inhibited unprofessional behavior.

Since the authors of this article are active members of the FOAM community, several
speculations from experience can be made regarding that specific learning environment. The
FOAM community can be viewed as a large, well-known virtual community of practice [23]. The
association of ALiEM.com and this series with FOAM may have created an implied expectation
for professional conduct that is in alignment with the greater FOAM culture. The moderators
and active participants in our online discussions are viewed as core community members who
welcome and guide new participants as they transition from passive readers to welcomed active
participants. The ALiEM MEdIC moderators are trained to be professional and cordial
participants who exemplify the expected behavior, perhaps creating implicit expectations for
productive and respectful discussion [20]. Recall that, while the moderators were only usually
rated a three on the professionalism scale, this was because they rarely contributed
substantively to the discussion. Rather, they maintained their moderator role by politely
greeting, engaging, and encouraging the other participants.

Positive correlations were observed between a participant’s openness with their identity, the
number of comments they made (p < 0.01), and cases they discussed (p < 0.05). These results
also diverge from previous literature. An article that assessed the advantages and disadvantages
of pseudonymity suggested that aliases may be a valuable asset to online learning for
increasing participation and self-disclosure during group discussion [17]. They explained that
pseudonyms create a context of ‘managed ambiguity’ by permitting relationships while

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 selectively concealing or revealing elements of real-life identity. However, our findings reveal
that this may not hold true in all contexts. We propose that if the discussion takes place in an
environment that encourages mutual respect and professionalism, then aliases may not be
required to promote active participation. This finding supports the notion that social media
platforms in medical education must be critically examined to better understand their unique,
underlying relationship structures [23]. The ALiEM MEdIC platform demonstrates the promise
of professional online forums for educators that allow learners to engage with difficult issues
while retaining their professional identities using new media.

Limitations
The most significant limitation of this study was that it involved only a single online teaching
environment and may not be generalizable to other contexts. However, this limitation was
insurmountable as we are currently unaware of other online forums for medical professionals
with similar characteristics that engage in online problem-based discussion.

Additionally, although we utilized previously derived scales for anonymity and professionalism,
they had not previously been used in a medical education context. Operational definitions had
to be modified to suit our online environment and medical education community.

Finally, very few remarks were scored as unprofessional and this may have resulted in spectrum
bias [24]. There was also likely a ceiling effect (i.e., most of our scores were on the higher end of
the scales) since the score proposed by Kilner and Hoadley has a maximum of four points, and
many of our comments maxed out at four points. In Kilner and Hoadley’s original military
online population, they found that up to 11% of comments were unprofessional. In our
population, none (0%) of the comments scored were unprofessional, which is surprising based
on previous literature [9, 21-22]. This may have resulted from an innate spectrum bias (i.e.,
because of the type of community, the standards set forth by the ALiEM website, and the
website’s reputation), or because there were not enough comments to analyze (i.e., inadequate
power). Since the previous literature has seen a higher incidence of unprofessionalism, we feel
that it is more likely the former phenomenon at work here.

Conclusions
The ALiEM MEdiC Series has effectively generated an online community that is both open
about identity and professional. Expectations of professional and respectful behavior were
exemplified through the group moderators, norms of the online community, reputation of the
website, and objectives for each discussion. Further research is required to determine what
factors encourage openness and professionalism online.

Additional Information
Disclosures
Conflicts of interest: The authors have declared that no conflicts of interest exist.

Acknowledgements
Thank you to Dr. Michelle Lin for her support of our ongoing research and scholarship within
the field of online medical education.

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